403.3E1 HEPATITIS B VACCINE INFORMATION AND RECORD

The Disease

Hepatitis B is a viral infection caused by the Hepatitis B virus (HBV) which causes death in 1-2% of those infected.  Most people with HBV recover completely, but approximately 5-10% become chronic carriers of the virus. Most of these people have no symptoms, but can continue to transmit the disease to others.  Some may develop chronic active hepatitis and cirrhosis. HBV may be a causative factor in the development of liver cancer. Immunization against HBV can prevent acute hepatitis and its complications.

The Vaccine

The HBV vaccine is produced from yeast cells.  It has been extensively tested for safety and effectiveness in large scale clinical trials.

Approximately 90 percent of healthy people who receive two doses of the vaccine and a third dose as a booster achieve high levels of surface antibody (anti-HBs) and protection against the virus.  The HBV vaccine is recommended for workers with potential for contact with blood or body fluids. Full immunization requires three doses of the vaccine over a six-month period, although some persons may not develop immunity even after three doses.

There is no evidence that the vaccine has ever caused Hepatitis B.  However, persons who have been infected with HBV prior to receiving the vaccine may go on to develop clinical hepatitis in spite of immunization.

Dosage and Administration

The vaccine is given in three intramuscular doses in the deltoid muscle.  Two initial doses are given one month apart and the third dose is given six months after the first.

Possible Vaccine Side Effects

The incidence of side effects is very low.  No serious side effects have been reported with the vaccine.  Ten to 20 percent of persons experience tenderness and redness at the site of injection and low grade fever.  Rash, nausea, joint pain, and mild fatigue have also been reported. The possibility exists that other side effects may be identified with more extensive use.

 

CONSENT OF HEPATITIS B VACCINATION

I have knowledge of Hepatitis B and the Hepatitis B vaccination.  I have had an opportunity to ask questions of a qualified nurse or physician and understand the benefits and risks of Hepatitis B vaccination.  I understand that I must have three doses of the vaccine to obtain immunity. However, as with all medical treatment, there is no guarantee that I will become immune or that I will not experience side effects from the vaccine.  I give my consent to be vaccinated for Hepatitis B.

Signature of Employee (consent for Hepatitis B vaccination)

  

Date
     
     

Signature of Witness

  

Date

 

REFUSAL OF HEPATITIS B VACCINATION

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring the Hepatitis B virus infection.  I have been given the opportunity to be vaccinated with Hepatitis B vaccine at no charge to myself. However, I decline the Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease.  If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Signature of Employee (refusal for Hepatitis B vaccination)

  

Date
     
     

Signature of Witness

  

Date

I refuse because I believe I have (check one)

              started the series                        completed the series

 

RELEASE FOR HEPATITIS B MEDICAL INFORMATION

I hereby authorize                                           (individual or organization holding Hepatitis B records and address) to release to the                                Emmetsburg Community School District, my Hepatitis B vaccination records for required employee records.

I hereby authorize release of my Hepatitis B status to a health care provider, in the event of an exposure incident.

Signature of Employee 

  

Date
     
     

Signature of Witness

  

Date

 

 

CONFIDENTIAL RECORD

____________________________________________________        

Employee Name (last, first, middle)

  

Social Security No.
         

Job Title: 

        
         
 

Hepatitis B Vaccination Date

Lot Number

Site

Administered by

1

              

2

              

3

              
         
         

Additional Hepatitis B status information:

    
         
         
         
         

Post-exposure incident: (Date, time, circumstances, route under which exposure occurred)
         
         
         
         

Identification and documentation of source individual:
         
         

Source blood testing consent:

      
         
         

Description of employee's duties as related to the exposure incident:
         
         
         
         

Copy of information provided to health care professional evaluating an employee after an exposure incident:
         
         
         
         

Attach a copy of all results of examinations, medical testing, follow-up procedures, and health care professional's written opinion.
         

Training Record: (date, time, instructor, location of training summary)